Healthcare Provider Details

I. General information

NPI: 1255842092
Provider Name (Legal Business Name): TEAM MAKENA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ALA MOANA BLVD STE 400
HONOLULU HI
96813-4920
US

IV. Provider business mailing address

27051 TOWNE CENTRE DR STE 180
FOOTHILL RANCH CA
92610-2819
US

V. Phone/Fax

Practice location:
  • Phone: 949-474-1753
  • Fax: 949-251-5120
Mailing address:
  • Phone: 800-996-4001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: ERNESTINA SMITH
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 949-382-3919